The Lessons from History on Health Care Reform

With Congress returning from recess to consider health care legislation and the President set to deliver a major address on the subject to both houses of Congress tomorrow, a bit of history may be in order. An excellent starting place David Blumenthal’s and James Marone’s “The Heart of Power,” which I reviewed for the New York Times this past weekend. Here are the major points:

Universal health care has bedeviled, eluded or defeated every president for the last 75 years. Franklin Roosevelt left it out of Social Security because he was afraid it would be too complicated and attract fierce resistance. Harry Truman fought like hell for it but ultimately lost. Dwight Eisenhower reshaped the public debate over it. John Kennedy was passionate about it. Lyndon Johnson scored the first and last major victory on the road toward achieving it. Richard Nixon devised the essential elements of all future designs for it. Jimmy Carter tried in vain to re-engineer it. The first George Bush toyed with it. Bill Clinton lost it and then never mentioned it again. George W. expanded it significantly, but only for retirees.

All the while, the ideal of universal care has revolved around two poles. In the 1930s, liberals imagined a universal right to health care tied to compulsory insurance, like Social Security. Johnson based Medicare on this idea, and it survives today as the “single-payer model” of universal health care, or “Medicare for all.” The alternative proposal, starting with Eisenhower, was to create a market for health care based on private insurers and employers; he locked in the tax break for employee health benefits. Nixon came up with notions of prepaid, competing H.M.O.’s and urged a requirement that employers cover their employees. Everything since has been a variation on one or both of these competing visions. The plan now emerging from the White House and the Democratic Congress combines an aspect of the first (the public health care option) with several of the second (competing plans and an employer requirement to “pay or play”).

Devising a plan is easy compared with the politics of getting it enacted. Mere mention of national health insurance has always prompted a vigorous response from the ever-vigilant American Medical Association; in the 1930s, the editor of its journal equated national health care with “socialism, communism, inciting to revolution.” Bill Clinton’s plan was buried under an avalanche of hostility that included the now legendary ad featuring the couple Harry and Louise voicing their fears that the Clinton plan would substitute government for individual choice — “they choose, we lose.”

One lesson is that a new president must move quickly, before opponents have time to stoke public fears. After his 1964 landslide, Johnson warned his staff to push Medicare immediately because “every day while I’m in office, I’m going to lose votes. I’m going to alienate somebody. We’ve got to get this legislation fast.” George W. Bush started planning what became the Medicare drug benefit months before he was elected.

Clinton, by contrast, suffered from delay. Right after his election, national health insurance looked so likely that even some Republicans began lining up behind various plans. A year later, it was dead. In the interim, battles over Clinton’s budget and Nafta drained his political capital, gave his opponents ample time to rouse public concerns about government-sponsored health care and soured key allies like organized labor and the AARP.

Congress can be just as much of an obstacle: one lesson from history is that a president must set broad health reform goals and allow legislators to fill in the details, but be ready to knock heads together to forge a consensus. “I’m not trying to go into the details,” Johnson repeatedly said of his Medicare bill, yet he flattered, cajoled, intimidated and bluffed recalcitrant members until they agreed. “The only way to deal with Congress is continuously, incessantly and without interruption,” he quipped.

Carter, on the other hand, pored endlessly over his incipient health care plan, scribbling opinions in the margins about every detail, and dealt with Congress at arm’s length. And Clinton delivered a plan so vast and complex that even a Democratic Congress chose simply to ignore it. Republicans, meanwhile, decided that a defeat of Clinton’s health care bill would be seen as a repudiation of the new administration and might give them a shot at retaking the House and Senate.

Presidents who have been most successful in moving the country toward universal health coverage have disregarded or overruled their economic advisers. Plans to expand coverage have consistently drawn cautions or condemnations from economic teams in every administration, from Harry Truman’s down to George W. Bush’s. An exasperated Lyndon Johnson groused to Ted Kennedy that “the fools had to go to projecting” Medicare costs “down the road five or six years.” Such long-term projections meant political headaches. “The first thing, Senator Dick Russell comes running in, says, ‘My God, you’ve got a one billion dollar [estimate] for next year on health. Therefore I’m against any of it now.” Johnson rejected his advisers’ estimates and intentionally lowballed the cost. “I’ll spend the goddamn money.” An honest economic forecast would most likely have sunk Medicare.

It’s not so much that presidential economic advisers have been wrong — in fact, Medicare is well on its way to bankrupting the nation — but that they are typically in the business of thinking small and trying to minimize risk, while the herculean task of expanding health coverage entails great vision and large risk. Economic advice is important, but it’s only one source of wisdom.

Yet since Johnson, presidents have found it increasingly difficult to keep their economists at bay, mainly as a result of the growth of Washington’s economic policy infrastructure. Cost estimates and projections emanating from the White House’s Office of Management and Budget and the Congressional Budget Office, both created during the Nixon administration, have bound presidents within webs of technical arguments, arcane rules and budget limits. To date, Democratic presidents have felt more constrained by this apparatus than Republicans, perhaps because they have felt more of a need to prove their cost-cutting chops.

President Obama seems to have anticipated many of these lessons. He’s moved as quickly on the issue as this terrible economy has let him, and he has not been too rattled by naysaying economists (although the cost estimates of the Congressional Budget Office set him back). But although he outlined his goals but left most details to Congress, the lesson from history is that he may have waited too long to force a deal on that disorderly body (especially disorderly when Democrats are in charge). The question remains whether, in the weeks and months ahead, he can knock Congressional heads together to clinch it, and overcome those who inevitably feed public fears about a “government takeover” of health care and of budget-busting future expenditures. He needs to work fast, and be tough as nails. But even if Obama fails, there is an art to losing, too — in a way that can tee up the issue for future presidents. Truman lost but nonetheless redefined the terms of debate, setting the stage for Medicare (which is why Johnson honored Truman when he signed it into law). Compare him with Clinton, who walked away from the wreckage of his health care plan and rarely mentioned the subject again. This allowed opponents to gain control over the spin and history, so that the Democrats’ signature cause slipped out of political sight for a decade.

Any history of the fight for universal care in America contains a subplot with a supporting actor who, although he never became president, is repeatedly heard from offstage — goading, pushing, threatening and pulling presidents of both parties toward universal coverage. Ted Kennedy first introduced his ambitious national health insurance proposal 40 years ago, and he never stopped promoting the cause. A deal he reached with President Nixon was the closest this country has ever come to universal care. Even before Kennedy’s death last month, his illness had tragically sidelined him just when his powerful voice was most needed. Yet when and if America ever achieves universal coverage, it will be due in no small measure to the tenacity and perseverance of this one remarkable man.